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Rationing in the NHS

Is care rationed in the NHS?  Should it be?

This is an issue I’ve come up against a few times recently and it’s left me a bit confused.  On the one hand, if there’s any hint that care may be withheld because of the cost, the screams from the press are as loud as any from the patient.  But on the other, it seems quite clear that there is rationing.

The Nuffield Trust wrote a briefing on the issue before the 2010 election and it provides a good guide to the way rationing works in the NHS, the contradictions within the system and the public’s views on it.  The briefing concludes that rationing happens, whether we like it or not and that there is not a comprehensive approach to it, but rather we muddle through, with some transparency at the margins, but a lot left to individual clinical judgement.

However I wasn’t sure it quite addressed the issue I’d come up against: how we seem to hold contradictory views on the issue.

First there was the panel discussing whether individuals should be allowed particular treatments not normally covered by the NHS (or, more precisely, not commissioned by the local CCG), such as those things like breast augmentation considered to be cosmetic.  (Not that it’s not always clear cut.  What if the ‘cosmetic’ problem is causing severe psychological distress, such as due to bullying or sense of body image?)  Anyway, in one particular case, the chairman of the committee looking at cases noted, ‘That’s expensive’, before immediately adding ‘but we mustn’t take cost into account.’  So if it’s a genuine need, we pay for it, whatever the cost?

Then there was the policy brought to the CCG.  A drug was now available generically, so being much cheaper it could be made available more readily (as a ‘first line’ treatment).  Other drugs, still only available in licensed form (and therefore more expensive) should still be available as ‘second line’ options.  However, for those more expensive drugs fewer doses per month would be allowed, “in order to sustain affordability, as increasing spend in this area would mean disinvesting from treatments for other NHS patients.”

So the NHS is very clearly rationing how much it spends on different treatments.  But then, we knew that already didn’t we?  That’s NICE’s job, to decide which drugs and treatments are cost effective, generally using the criterion of £30k per quality adjusted life year (QALY) as the limit.

So if there is rationing, why was that chairman saying cost shouldn’t matter?  Why do the press get apoplectic at the thought of rationing, such as when some cancer drugs are deemed not worth the money?  Are we just ignoring the contradictions?

Well, yes, to some extent, but there may also be some arguments which justify a balance of both approaches.

There are limited resources in the NHS as elsewhere and by allocating them to where they produce most value you get better outcomes overall (a fundamental principle of economics).  But we don’t like to think of people and their health in terms of resources, costs and benefits.  That’s partly squeamishness, but there may also be a pragmatic case because of the wider implications.

It would be perfectly logical to make arguments at the level of the individual, but generally we don’t.  So we could potentially say that in general this drug is cost effective but it isn’t likely to extend the life of this particular individual because of their health and circumstances, so we won’t give it to them.  This person is old, so the operation would be a bit of waste – they haven’t got that many years left.  This person has multiple problems, and while each one individually is cost effective, that person is just not worth the money.  While such an approach might be logical, it’s fraught with risks.  We start having to make judgements about individuals and it is difficult to guarantee they will be objective.  Will those making the decisions be swayed by extraneous factors (like attractiveness, power, wealth)?  Should someone receive expensive treatment when they have a wretched, miserable life anyway, so they will benefit less than the happy person in good circumstances?  Is this person more deserving of care than that person?

That is clearly a slippery slope and so something we avoid (although it is possible that some such judgements get smuggled into ‘clinical decisions’).  It is much safer to say everyone is eligible for whatever care they need on the same terms.  We work on the average benefit of different treatments, regardless of whether it is cost effective for any particular individual.  So we have a distinction we can apply: people aren’t rationed but the terms of care (what drugs or treatments can be afforded) are.  Ration the pills but not the patients.

I think that is probably the broad approach we do adopt.  However, as the Nuffield Trust document makes clear, in practice it is more muddled and less consistent than this, with variations within as well as between CCGs as well as variations from the way ‘clinical judgement’ is exercised.

So we will still have difficult decisions to make, balancing being rational and humane.  But perhaps having this principle – ‘ration pills not patients’ – will help clarify some of the contradictions.

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